POSTPARTUM HEMORRHAGE (PPH)

British Columbia Section 2006

OVERVIEW OF PRESENTATION

Definitions Diagnosis Etiologies Risk Factors Management Options

DEFINITION

Excessive blood loss that makes the patient symptomatic (ie lightheadedness, vertigo, syncope) +/- signs of hypovolemia (ie hypotension, tachycardia, or oliguria) A subjective assessment Traditionally: (although they underestimate EBL)

EBL >=500 cc after vaginal delivery EBL >=1000 cc after a cesarean section Can also use a decline in Hct of 10% to define PPH

INCIDENCE

Affects 5-15% of women giving birth Two categories:

Early (primary) hemorrhage: occurs within the first 24 hours postpartum Late (secondary) hemorrhage: occurs after 24 hours postpartum

PREVENTION

Identifying the risk factors

Assess every womans risk for PPH and make appropriate arrangements for her care Will discuss later

Active management of the 3rd stage of labour

ETIOLOGIES: 4 Ts

Tone: uterine atony, ~ 1 in 20 deliveries Tissue: retained placental tissue Trauma: uterine, cervical or vaginal lacerations Thrombin: dilutional coagulopathy, consumptive coagulopathy and coagulation disorders

Uterine Atony

Most common cause of PPH Accounts for 75-80% of cases of primary PPH Need to be aware of risk factors

Risk Factors For Uterine Atony

Over distended uterus

Intra amniotic infection

Polyhydramnios Multiple gestation Macrosomia

Fever and/or prolonged labour

Uterine muscle exhaustion

Functional/anatomical distortion of the uterus

Rapid labour Prolonged labour High parity

Fibroid uterus Placenta previa Uterine anomalies

GENITAL TRACT TRAUMA and Risk Factors

Second most common cause of PPH Lacerations of cervix or vagina:

Precipitous delivery Operative delivery

Genital tract hematomas Uterine rupture:

spontaneous (1/1900 deliveries) blunt trauma (eg. MVA) previous uterine scar

GENITAL TRACT TRAUMA and Risk Factors

Lacerations/extensions at C-section:

Prolonged labour Malposition Deep engagement

UTERINE INVERSION and Risk Factors

Iatrogenic During 3rd stage of labour:

inversion traction on peritoneal structures vasovagal response vasodilation increased bleeding and risk of hypovolemic shock

Risk factors:

High parity Fundal placenta

Retained Products of Conception and Risk Factors

Retained blood clots:

Atonic uterus Abnormal Placenta: accreta, percreta, succenturiate lobe Previous uterine surgery (ie: myomectomy) High parity Incomplete placenta at delivery

Retained products:

Coagulation Abnormalities and Risk Factors

Pre-existing states:

Hemophilia A Von Willebrands Disease

History of hereditary coagulopathies History of liver disease

Therapeutic anti-coagulation:

History of blood clots

Coagulation Abnormalities and Risk Factors contd

Acquired in pregnancy:

ITP Pre-eclampsia and thrombocytopenia DIC

Pre-eclampsia Dead fetus in utero Severe infection Abruption Amniotic fluid embolism

Active Management of the 3rd Stage

Use of uterotonic drugs after the delivery of the anterior shoulder:

Oxytocin 10 U IM, 5 U by IV push or 10-20 U per litre IV drip running at 100-150 cc/hr

Early cord clamping and controlled cord traction Ensure continued uterine contraction post delivery of placenta by fundal palpation and massage if necessary Inspect placenta for completeness

Approach to Identifying Etiology

Abdominal palpation: boggy vs. firm uterus, ?uterine inversion Careful inspection of cervix, vagina, vulva and perianal area for lacerations and/or hematomas Manual exploration of uterine cavity: remove clots, retained tissue? Consider coagulopathy if no other cause identified

PRIMARY MANAGEMENT ABCs

Notify attending physician and other staff Monitor vital signs, urine output, possible foley 1 large bore IV Type of cross-match 2-4 units of PRBCs Fluid resuscitation with crystalloids Baseline blood work for Hgb, hematocrit, platelets and coagulation profile Then proceed with directed treatment

TREATMENT OF UTERINE ATONY

Bimanual compression and massage of uterus Drugs:

Rapid, continuous infusion of dilute IV oxytocin (40-80 U in 1L NS) Misoprostil (Cytotec, PGE1): 800-1000 mcg rectally Methylergonovine maleate (Methergine): 0.2 mg IM repeat q5mins as needed up to 5 doses:

Contraindicated in women with hypertension

Prostaglandin F2 analogues (Hemabate): 0.25 mg IM repeat q15 mins prn up to 8 doses

Contraindicated in those with asthma/brochospasm

TREATMENT OF UTERINE ATONY

Methods to Tamponade the Uterus

Uterine packing

Pack uterus with gauze layering from one cornua to the other with a sponge stick ending such that the gauze is allowed to extend though the cervical os Insert balloon Instil 300-500cc saline Can insert one or more bulbs Instil 60-80cc of saline

SOS Bakri Balloon/other brand uterine balloons

Foley catheter

TREATMENT OF GENITAL TRACT TRAUMA

Lacerations: identify and repair with continuous interlocking sutures Large expanding hematomas

Sx: Pelvic or rectal pressure, pain Tx: Drain the blood within the hematoma, can place a drain in situ, suture the incision, vaginal packing or interventional radiology if hematoma expansion cannot be tempered

TREATMENT OF GENITAL TRACT TRAUMA

Uterine rupture: repair small defects, may need total abdominal hysterectomy Uterine inversion

Can replace manually by placing the palm of the hand against fundus and by exerting upward pressure with the fingertips circumferentially May need to relax uterus with agents such as magnesium sulfate, halothane, terbutaline or nitroglycerin in order to replace uterine corpus

TREATMENT OF RETAINED PLACENTAL TISSUE

Manual removal Curettage (with a large curette) Extensive placenta accreta may need a hysterectomy

TREATMENT OF COAGULOPATHY

Reverse anticoagulation Von Willebrands disease:

Desmopressin before the surgery and post for severe hemorrhage Platelet concentrate, cryoprecipitate, fresh frozen plasma, platelets, packed RBCs

Replace Factors:

INTRACTABLE PPH

Get help

Notify OB, anesthesia and ICU Manual compression and packing of uterus Vasopressin at site of bleeding in c-section Crystalloids and blood products to maintain urine output, BP and coagulation

Local control

BP and coagulation

Consider angiographic embolization

Intractable PPH - Surgical Approach

Repair of lacerations Surgical uterine compression techniques

Example: B-Lynch Uterine arteries Internal iliacs

Ligation of vessels

Emergency Hysterectomy Uterine artery/internal iliac embolization

Delayed (Secondary) PPH

Between 24hrs and 12 weeks postpartum Affects 0.5 2 % of women Secondary to atony due to retained products Management:

Uterotonic agents Antibiotics Possible D&C

COUNSELLING

Women with a prior PPH have ~ 10% risk of recurrence in a subsequent pregnancy Always consider preventative measures Counsel appropriately Take appropriate measures

REFERENCES:

Prevention and Management of Postpartum Haemorrhage. SOGC clinical guidelines. JOGC, April 2000 Postpartum Hemorrhage. ACOG Practice Bulletin No. 76. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006: 108:10391047. Jacobs, A. Causes and treatment of postpartum hemorrhage. Uptodate online (14.3)